stereotypes

I’m looking for opinions/advice on how to deal with people doing impressions of others. A lot of the guys here like to do “impressions” of various attendings. To me it feels like mocking them for being older than us, or for having a pet phrase or two, or for always approaching a problem in the same way. I’m not sure whether it’s mocking, though. They don’t do it as much about the attendings we don’t like as about the nice attendings. But of course they wouldn’t do it if the attending was around, and I’m pretty sure the attendings wouldn’t like it if they heard it. I wish I could stop these conversations, but I don’t know what to say.

Ok, that’s the Dear Abby section for today. Now, some stereotypes from another angle:

Another group that my colleagues like to do imitations of are medicine residents in general (not one in particular). At one point today I had decided that was really enough, and we were setting a bad example for the medical students, and I needed to do something to slow it down, or at least demonstrate that we do respect our colleagues. And then we got a consult from the medical ICU, and the medicine resident said, at various points in the conversation, “I know there’s nothing you can do for this guy, but my attending said, ‘He’s crashing, and I’m not sure what to do about it; consult surgery.’ . . . Yes, I’ve been here all morning; it took me four hours to put in a central line, that’s why I didn’t call you earlier. . . Sure, take the chart, I’m going to be writing a note here for quite a while longer [1hr, by my count]. . . We were going to get an ultrasound to evaluate the ascites. You guys don’t do that kind of thing, do you? You just touch it.”

That, my friends, is an admission I could not make up. Every single medicine stereotype that the other surgery residents had been quoting to the med students, in living color – from one of the smartest, most competent (except for lines) medicine residents. He knew the consult was ridiculous. At least he called us about it, and we had an intelligent conversation about the patient. (And as for the ascites, yes: we had a CT, and an abdominal exam. No need to be repetitious with the ultrasounds, except if you intend to tap it. At the beginning of this year, I was puzzled when called upon to say whether someone’s abdomen was distended or not. I couldn’t tell the difference between distention (which is usually pathological) and obesity (which is physiological – not an immediate surgical pathology). I’ve learned the difference now, though. Distention, even an obese person, gives a different texture, a different quality under the skin. It’s fluid, or air, that shouldn’t be there; and you can sense how the skin is stretched in an unusual way to accomodate it.)

And then finally, another group whom I have decided to abandon all scruples concerning, and make bitter and sarcastic remarks about without reserve: the ER, and especially the ER residents. I think, honestly, ER doctors with specialty residents in-house are obliged to do better than this, because they think a bit longer before calling an attending in from home, than before calling a resident down the stairs.

Today, ten minutes before sign-out, we got a page from the ER, for a young man who had arrived only 15 minutes before. (I know, because we were down there evaluating a genuine surgical issue when the fellow was brought back.) The consult was for appendicitis in a patient with no other medical problems. No labs had been done, and certainly no imaging. We went to see the patient, and a few moments later informed the ER resident that in our opinion, a young man with groin/testicular pain as well as right lower quadrant pain, who had a history of both kidney stones and Crohn’s disease, deserved a little investigation into other possible causes of pain (testicular torsion, kidney stones, Crohn’s disease) before being summarily dumped on the general surgery service as an appendicitis. (If it were one of those other causes, he should have been sent to urology, or colorectal surgery, or even plain medicine.) So I apologize to the excellent ER doctors in the blogosphere, but I’m giving up being polite about the ER for right now. From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up. And all stereotypical jokes are fair game. As my chief remarks, we’re not asking them to think like surgeons, just like doctors. Examine the patient and think for two minutes!

(My patient is dying of cancer, and I can’t fix him, I can’t help him, I can’t even make him comfortable. Every time I go to see him, he holds my hand and cries. I hate cancer. My patients are all sick, and I can’t fix them. I’m tired of sick people. Did you know everyone in the hospital is sick? I forget what healthy people look like. All my patients end up in the ICU. The world is broken and I can’t mend it. . . The creation also shall be delivered from the bondage of corruption into the glorious liberty of the children of God. The whole creation groans and travails in pain together until now; and not only they, but we also, who have the first fruits of the Spirit, groan within ourselves, waiting for the adoption, to wit, the redemption of our bodies. And we are saved by hope, but hope that is seen is not hope, for what a man sees, why does he yet hope for? Likewise the Spirit also helps our infirmities. . .)

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11 Responses to “stereotypes”

From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up.

I don’t advise it. You see, the ER can take care of you or make your life hell. The surgeons we don’t like get 2AM phone calls to arrange follow-up for routine cholecystitis. (That is what the surgeons asked us to do in our joint department meeting, after all.) But the *good* surgeons, meaning the skilled ones who are personal, helpful, and understand that we are friends and colleagues, are the ones we will go the extra mile to protect and help out. Relationships matter.

Better advice: learn who the good ER docs/residents are. Build bridges with them. The ones who need training — take a moment to teach instead of belittle and antagonize. It’s a small investment which will pay dividends in the future.

Ice Queen – Sure, that’s the right answer. But something’s wrong with my radar, I can’t figure out what he would do. As I said, if I were sure it was being done out of respect to these attendings, it wouldn’t matter so much. I guess the fact that we would all shut up fast enough if they walked into the room ought to make it clear.

The imitations are universal in my program– it’s sort of a requirement. Even my program director does it with us. It’s not considered disrespectful– usually it’s just staff that we like.
As for ER doctors…well, I shouldn’t say anything, but I did crack up reading your account.

“but I’m giving up being polite about the ER for right now. From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up”

I am sure you are upset, but this is certainly not the way to go. I love reading your blog, and even though you seem to be cynical at times, you tend to bring a cheerful and rarely seen Christian attitude towards medicine. I think you could benefit from being “Doc Sunshine” than Doc Bitter (see Suburban Emergency link below)

I think the comment about figuring out which residents you can trust is a reasonable one. I’m a second year EM resident and I only call surgery for a consult if a) it’s a post-op pt within 30 days of surgery (our hospital policy), b) I need surgery to do a specific thing (i.e. go to the OR, determine if an abscess that appears deep needs to go to the OR, etc.), or my least favorite, c) my attending is making me. I don’t like calling my surgical colleagues for crap consults and I will argue with my attending before I make the call, and when I make it, I will start the consult with, “I think this is an unnecessary consult, and I apologize in advance, please know that my attending is making me and I argued with him/her about it.”

That being said, only once in my life have I called surgery for appendicitis with no labs, no imaging, just a set of vitals and my physical exam. I walked in, the young gentleman had a rigid abdomen, worse in the RLQ, with rebound, and I added type and screen and coags to the lab and called surgery. The consult took longer than I expected, and I kept calling to make sure that the pt was actually going to be seen, frustrating and an unusual delay from our surgical residents. It took two hours for someone to come lay hands on his belly. I think they were waiting for the labs or something. He had perforated appendicitis and went to the OR as soon as they actually examined him. It was frustrating to me because I had never made that call before, had never said “rigid abdomen” and “needs the OR soon” over the phone calling a consult, and I probably won’t for another five years, but with a long delay. I think our surgical residents were somewhat worn down with impressive sounding stupid consults and I did not know how to impress upon them enough that this guy had peritonitis and was going to the OR in the next few hours (saying “This guy has peritonitis and is going to need to be in the OR in the next few hours” was not effective, btw). So please don’t get too jaded. Some of us prefer to do our own work-up and make a serious attempt to not waste your time. Please remember that.

Sarah – I appreciate your comments. You sound like the kind of ER doctor I would like to take calls from. Your story does sound frustrating, but good call on your part. We try to see every consult from the ER within minutes, certainly within 30-45 minutes even when we’re busy. If we hear something concerning, like appendicitis/mesenteric ischemia/strangulated or incarcerated hernia/lengthy course of small bowel obstruction, we’ll come immediately, even without labs. And there are indeed some resident whom we respect and trust more than others, and I’ve learned to regret disregarding their impressions of a patient. But this wasn’t one of those residents.

As an ER doc, I say “mock away.” But from where I am sitting, surgeons make at least as many mistakes as my colleagues, so remain humble about it.

As for what Jesus would do, it isn’t hard to say. He commanded us to love our enemies and forgave those who crucified him, but didn’t mind calling the Pharisees white-washed tombs and vipers, or calling King Herod a vixen (f.) (surely mockery if anything is). Respect your authorities, submit to one another in love, and mock openly as a teaching tool.